Washington Nationals ace Stephen Strasburg is out for the remainder of the season. It's not the feared ulnar collateral ligament tear, which often results in Tommy John surgery, but something equally devasting to pitchers. Strasburg underwent surgery for thoracic outlet syndrome.
Thoracic outlet syndrome comes in two forms - neurologic and vascular. Neurologic is far more common, representing 95% of cases, and is the compression of nerves (the brachial plexus) originating in the neck. The brachial plexus is responsible for all sensation and movement of the arm. When the nerves are continuously compressed, numbness, tingling, and weakness can result. Vascular type is the compression of the subclavian artery or vein, often resulting in pain, swelling, and/or change in color or temperature of the arm.
As you can imagine, both types impair a pitcher's ability to throw a baseball. Strasburg was diagnosed with neurogenic thoracic outlet.
Thoracic outlet syndrome carries some controversy in the medical community. It is difficult to diagnose and rare. Imaging only looks at still positions, impairing the provider's ability to see compression with activity and multiple positions. Treatment options lack strong research as well.
Initial treatment is often physical therapy. If that fails, surgery may be recommended. Failing to make sustained progress and having another five years on his contract, Strasburg elected to go the surgical route.
Surgery for thoracic outlet involves either the removal of the first rib, a cervical rib, or muscles potentially compressing the nerves or vasculature causing the symptoms. Most protocols call for a 12 week recovery period, but the time to return to high-level pitching is much higher. One of the most recent MLB pitchers to return from the procedure, Matt Harvey, took 11 months.
A recent study showed 20 out of 27 (74%) MLB pitchers returned to the MLB level after undergoing thoracic outlet syndrome. Their performance was a mixed bag. Fastball velocity and strike percentage were equivalent to preinjury levels, but ERA worsened by almost a full run. This is a small sample size, however, making variability large. This is evident in the time to return to play stats. The average return to MLB play time was 297 days (just under 10 months). The range was 105-638 days.
Washington hopes to have Strasburg back at the start of the season. It is possible but tough to determine this close to the procedure. With Washington currently shopping Strasburg and Turner, they may be in the midst of a rebuild. It is unlikely to be a full-scale teardown, but with a weak farm system, it is possible. Given the status of the franchise and stage of the season, there is little incentive for Washington to rush Strasburg back to the mound.
We are in the wait-and-see stage and should know more as spring training approaches.
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